Contracts govern many activities of individuals, companies, and other entities. The terms of contracts between the contracting parties are important for defining roles, responsibilities, rights, and obligations of each party. As one example, contracts govern the relationships between many service providers and insurers. For instance, in the third-party payer health care industry, a “third party” (referred to herein generally as an “insurer”) pays for health care services received by a member (or “insured”) from a service provider (any person, such as a doctor, nurse, dentist, pharmacist, etc., or institution, such as a hospital or clinic, that provides medical care). Examples of such third-party payers (or “insurers”) include an insurance company (e.g., BlueCross® BlueShield®, Aetna® Inc., etc.), Health Maintenance Organization (“HMO”), Preferred Provider Organization (“PPO”), or the Federal Government (e.g., Medicare). The insurers negotiate with the service providers (e.g., hospitals, doctors, etc.) various terms, including the amounts (and corresponding conditions) that the insurers will pay the service providers for services rendered to the members of the insurers. For instance, a negotiated contract may specify that an insurer will pay a service provider X amount for performance of a given procedure (e.g., caesarean-section procedure, open heart surgery, blood test, routine physical exam, LASIK eye surgery, dental root canal, prescribed pharmaceuticals, etc.) for one of its members. The contract may specify those procedures for which the insurer will reimburse the service provider, as well as the corresponding reimbursement rates for each procedure. Of course, any arrangement imaginable that is agreeable to both parties may be provided for in the contracts, and such terms are becoming increasingly complex. The negotiated terms generally differ from service provider to service provider as the types of services and specialties of each service provider may differ. At any given time, an insurer may have many contracts in force for governing its relationship with its service providers.
Contract management systems are known for monitoring the contracts (e.g., to remind parties of their respective rights and obligations under the contract). More particularly, contract management systems may monitor which contracts are in place at any given time and remind parties as to their performance obligations as such obligations arise and contract renewals. As examples, such contract management systems are available from diCarta, Inc. (e.g., the diCarta Contracts Version 5 software solution) and Contract Management Solutions, Inc. (CMSI) (e.g., the CMSI 6.1 Software Suite). Particularly considering the large number of contracts that are in force at any given time for an insurer, the contract management systems are important tools for aiding the insurer in managing the life cycle of its various contracts from reminding the insurer of upcoming renewals to aiding the insurer during the negotiation process with a service provider to aiding the insurer in monitoring its obligations under an executed contract.
Typically, once contract terms are agreed upon and a contract is executed by the parties, the insurer provides the contract terms to an operator who interprets the terms and attempts to manually configure their contract management system in accordance with such terms. Particularly considering the increasing complexity of many terms in such contracts, the actual negotiated terms may differ materially from the configuration of the contract management system as a result of errors in the manual configuration process. In addition to the human errors that may arise in manually configuring an insurer's contract management system in accordance with an executed contract with a given service provider, such manual configuration also incurs undesirable delays in having the newly executed contract incorporated into the contract management system.
Additionally, claims processing systems are often implemented by an insurer, which are intended to at least partially automate the processing of claims received from service providers by insurers in accordance with the terms of the governing executed contracts. Thus, typically once contract terms are agreed upon and a contract is executed by the parties, the insurer's claims processing system is configured in accordance with such terms for processing claims received from the service provider (e.g., for determining the proper price to be paid by the insurer for a given claim in accordance with the terms of the governing contract).
Traditionally, the claims processing systems and the contract management systems are disparate systems, and the configurations of those systems to reflect the terms of a given contract are performed separately and thus do not ensure that the contract terms are reflected consistently across the various systems.